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More on diet and risk of gout

Clinical bottom line

Red meat and seafood consumption are associated with an increased risk of gout, while purine-rich vegetables and total protein are not. Low-fat dairy products, on the other hand, are associated with a decreased risk. It is clearly not simply that high purine content in food is bad for gout.


Reference

HK Choi et al. Purine-rich foods, dairy and protein intake, and the risk of gout in men. NEJM 2004 350:1093-1103.


Background

Patients with gout are usually advised to avoid purine-rich foods, or to limit intake of animal protein, but the evidence for this reducing recurrence of gout is poor. One study has reported on the relationship between reported intake of purine-rich foods, dairy foods and protein and the incidence of gout.

Study

This was a large, prospective cohort study involving 49,150 men, aged 40 to 75 years, who completed a questionnaire about diet, medical history and medications in 1986, and who did not have gout. The questionnaire inquired about consumption of over 130 foods and beverages over the past year, and was updated in 1990 and 1994. For analysis, the average daily intake of each food group was categorised into quintiles. At baseline and every two years afterwards, participants provided information about weight, medications and medical conditions. Follow-up was more than 90%.

Results

There were 730 confirmed new cases of gout (using ACR criteria) during the 12 years of follow-up. The incidence increased with age, peaking between 55 and 69 years.

Purine-rich foods

Increased consumption of meat was associated with an increased risk of gout, but for individual types of meat only beef, pork and lamb as a main dish had this association. Increased consumption of seafood was also associated with an increased risk of gout, and all individual items carried this risk. Increased consumption of purine-rich vegetables was not associated with increased risk of gout, either as a group or individually.

Dairy products

Increased consumption of dairy products was associated with a decreased risk of gout, and was due to a decreased risk associated with consumption of low-fat products such as skimmed milk and low-fat yogurt.

Table 1. Relative risk of gout for different food groups

Food group
Relative Risk* per additional daily serving
meat
1.21 (1.04 to 1.41)
seafood
1.07 (1.01 to 1.02)
purine-rich vegetable
0.97 (0.79 to 1.19)
low-fat dairy
0.79 (0.71 to 0.87)
full-fat dairy
0.99 (0.89 to 1.10)
* multivariate relative risk

 

Protein

Total protein intake and animal-protein intake were not associated with risk of gout. Increased consumption of vegetable-protein or dairy-protein was, however, associated with decreased risk.

Table 2 Relative risk of gout according to protein consumption

Source of protein
Relative Risk* for highest compared with lowest quintile
total protein
1.07 (0.84 to 1.36)
animal protein
0.96 (0.74 to 1.23)
vegetable protein
0.73 (0.56 to 0.96)
dairy protein
0.52 (0.40 to 0.68)
* multivariate risk

 

Body mass and alcohol

Body mass index and alcohol consumption did not affect associations between the risk of gout and most dietary factors. The association with increased seafood intake, however, was stronger for men with body mass index less than 25 compared to 25 or more.

Definition of gout

When the analysis was repeated using increasingly specific definitions of gout (self-reported, ACR criteria, crystal-proven), the magnitude of the associations with different food groups tended to increase, but null associations remained null.

Comment

Evidence of links between purine-rich diets and gout has been based on metabolic experiments assessing the effect of short-term loading of purified purines on serum uric acid levels. This prospective study looks at real food in real people and uses a clinical, rather than surrogate, endpoint. Although a cohort study cannot prove cause and effect, this does provide clinically useful information.

Red meat and seafood consumption are associated with an increased risk of gout, while purine-rich vegetables and total protein are not. Low-fat dairy products, on the other hand, are associated with a decreased risk. It is clearly not simply that high purine content in food is bad for gout. Other factors including genetic susceptibility, the quantities of individual purines, their bioavailability, and the effects of cooking and processing are probably also playing their part.